Alain C. Corcos

Evolving role of endovascular techniques for traumatic vascular injury: a changing landscape?

Background: Endovascular management of blunt aortic injury has dramatically reduced the morbidity and mortality associated with this specific injury. There remains a paucity of evidence quantifying the beneficial effects associated with endovascular (ENDO) techniques for other vascular injury types and little information regarding the impact ENDO techniques have had on the management of traumatic vascular injuries over time. Methods: We performed a retrospective analysis of data from the National Trauma Data Bank over 2002 to 2006 and 2008 time periods (NTDB 7.2 and RDS 2008). Injured patients undergoing any arterial vascular repair procedure using ENDO or standard open techniques were determined using ICD-9-CM procedure codes. Abbreviated Injury codes were used to select patients who suffered subclavian, carotid, or thoracic aortic injury. Logistic regression was used to determine whether EARLY ENDO procedures (first 24 hours after injury) were independently associated with a lower risk of mortality. Results: The percentage of ENDO procedures significantly increased over time irrespective of mechanism of injury. When aortic (thoracic), subclavian, and carotid arterial injuries were analyzed, a significant decrease in mortality over time was found. The percentage of ENDO procedures for all arterial injury subtypes significantly increased in the RECENT (2008) period. Seventy-five percentage of ENDO procedures occurred early (initial 24 hours) with 20% of those patients being hypotensive upon arrival (systolic blood pressure <90 mm Hg). For patients who had vascular procedures in the RECENT period, regression analysis revealed that early ENDO procedures were independently associated with a 35% reduction in mortality risk (odds ratio, 0.65; 95% confidence interval, 0.5–0.8) after controlling for major confounders including mechanism of injury and presence of hypotension on arrival. Conclusion: ENDO procedures for arterial injury have increased over time while mortality for arterial injury subtypes has significantly decreased. Early ENDO procedures are common and are independently associated with a lower risk of mortality. These results suggest outcomes after vascular injury may benefit from ENDO expertise and that ENDO techniques should be incorporated into the early treatment algorithm of trauma patients with vascular injury, particularly those that require difficult operative exposure. Level of Evidence: III

The splenic injury outcomes trial: An American Association for the Surgery of Trauma multi-institutional study.

BACKGROUND Delayed splenic hemorrhage after nonoperative management (NOM) of blunt splenic injury (BSI) is a feared complication, particularly in the outpatient setting. Significant resources, including angiography (ANGIO), are used in an effort to prevent delayed splenectomy (DS). No prospective, long-term data exist to determine the actual risk of splenectomy. The purposes of this trial were to ascertain the 180-day risk of splenectomy after 24 hours of NOM of BSI and to determine factors related to splenectomy. METHODS Eleven Level I trauma centers participated in this prospective observational study. Adult patients achieving 24 hours of NOM of their BSI were eligible. Patients were followed up for 180 days. Demographic, physiologic, radiographic, injury-related information, and spleen-related interventions were recorded. Bivariate and multivariable analyses were used to determine factors associated with DS. RESULTS A total of 383 patients were enrolled. Twelve patients (3.1%) underwent in-hospital splenectomy between 24 hours and 9 days after injury. Of 366 discharged with a spleen, 1 (0.27%) required readmission for DS on postinjury Day 12. No Grade I injuries experienced DS. The splenectomy rate after 24 hours of NOM was 1.5 per 1,000 patient-days. Only extravasation from the spleen at time of admission (ADMIT-BLUSH) was associated with splenectomy (odds ratio, 3.6; 95% confidence interval, 1.4–12.4). Of patients with ADMIT-BLUSH (n = 49), 17 (34.7%) did not have ANGIO with embolization (EMBO), and 2 of those (11.8%) underwent splenectomy; 32 (65.3%) underwent ANGIO with EMBO, and 2 of those (6.3%, p = 0.6020 compared with no ANGIO with EMBO) required splenectomy. CONCLUSION Splenectomy after 24 hours of NOM is rare. After the initial 24 hours, no additional interventions are warranted for patients with Grade I injuries. For Grades II to V, close observation as an inpatient or outpatient is indicated for 10 days to 14 days. ADMIT-BLUSH is a strong predictor of DS and should lead to close observation or earlier surgical intervention. LEVEL OF EVIDENCE Prognostic/epidemiological study, level III; therapeutic study, level IV.

Characterization of sex dimorphism following severe thermal injury.

Sex-based outcome differences have been previously studied after thermal injury, with a higher risk of mortality being demonstrated in women. This is opposite to what has been found after traumatic injury. Little is known about the mechanisms and time course of these sex outcome differences after burn injury. A secondary analysis was performed using data from a prospective observational study designed to characterize the genetic and inflammatory response after significant thermal injury (2003–2010). Clinical outcomes were compared across sex (female vs male), and the independent risks associated with sex were determined using logistic regression analysis after controlling for important confounders. Stratified analysis across age and burn severity was performed, whereas Cox hazard survival curves were constructed to determine the time course of any sex differences found. During the time period of the study, 548 patients met inclusion criteria for the cohort study. Men and women were found to be similar in age, TBSA%, inhalation injury, and Acute Physiology and Chronic Health score. Regression analysis revealed that female sex was independently associated with over a 2-fold higher mortality after controlling for important confounders (odds ratio, 2.2; P = .049; 95% confidence interval, 1.01–4.8). The higher independent mortality risk for women was exaggerated and remained significant only in pediatric patients and demonstrated a dose–response relationship with increasing burn size (%TBSA). Survival analysis demonstrated early separation of female and male curves, and a greater independent risk of multiple organ failure was demonstrated in the pediatric cohort. The current results suggest that sex-based outcome differences may be different after thermal injury compared with traumatic injury and that the sex dimorphism may be exaggerated in patients with higher burn size and in those in the pediatric age group, with female sex being associated with poor outcome. These sex-based mortality differences occur early and may be a result of a higher risk of organ failure and early differences in the inflammatory response after burn injury. Further investigation is required to thoroughly characterize the mechanisms responsible for these divergent outcomes.

Dabigatran etixilate and traumatic brain injury: Evolving anticoagulants require evolving care plans

AIM To investigate the outcomes of trauma patients with traumatic brain injury (TBI) on Dabigatran Etexilate (DE). METHODS Following IRB approval, all patients taking DE who were admitted to our level 1 trauma service were enrolled in the study. Injury complexity, length of stay (LOS), intensive care length of stay, operative intervention, therapeutic interventions and outcomes were analyzed retrospectively. RESULTS Twenty-eight of 4310 admissions were taking DE. Eleven patients were excluded on concurrent antiplatelet therapy. Average age was 77.14 years (64-94 years), and average LOS was 4.7 d (1-35 d). Thirty-two percent were admitted with intracranial hemorrhage. Eighteen percent received factor VII, and 22% received dialysis in attempts to correct coagulopathy. Mortality was 21%. CONCLUSION The low incidence, absence of reversal agents, and lack of practice guidelines makes managing patients with TBI taking DE frustrating and provider specific. Local practice guidelines may be helpful in managing such patients.

Suprahepatic inferior vena cava injury II.

A female was seen in the emergency department (ED) as a nontrauma alert after motor vehicle crash against a pole, where medics noted significant front end damage to the vehicle. The patient was boarded, collared, and transferred to the ED with normal vital signs. The initial evaluation in the ED (a trauma center) revealed a stable patient with a Glasgow Coma Scale (GCS) score of 15 and complaints of upper abdominal and right ankle tenderness. The workup revealed two areas of hypoattenuation within the left lobe of the liver consistent with liver lacerations and a 7.1 5.6-cm area of contrast pooling below the right diaphragm continuous with the inferior vena cava (IVC) suggestive of a contained rupture on an intravenous-contrasted computed tomographic (CT) scan of the chest, abdomen, and pelvis (Fig. 1). The patient also had a right pelvic fracture extending into the right acetabulum and a nondisplaced right calcaneal fracture.

Abstract: A Qualitative Survey Study of United States Burn Units

CONCLUSION: The study suggests the closed-loop technique significantly decreases time of fat transfer to an average of 15 minutes, a trend towards decreased overall complications, though not statistically significant, and good subjective fat retention beyond 12 months. This suggests the closed-loop method is safe, effective, and significantly decreases operating time. We continue to collect patients in the closed-loop cohort and are also analyzing variation in adipocyte viability between the two methods.